PCI complications: restenosis

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Editors-In-Chief: Alexandra Almonacid M.D.; Jeffrey J. Popma M.D. Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[1]


Restenosis can occur in the implanted stent after performing PCI. One of the classification systems categorized restenosis based on being multifocal or its location in the stent (such as at the edge of the stent, or at the articulation or gap. The main mechanism causing restenosis after stent implication is neointimal hyperplasia. Restenosis after drug eluting stent implantation is generally more focal than following bare metal stent placement. Risk of ISR is lowered after presentation of new generations stents such as DES compared to BMS and first-generation DES. Balloon angioplasty, drug eluting stents, drug-coated balloons, scoring or cutting balloons, and vascular brachytherapy are some of the common approaches that have been explored as the restenosis treatment. Among all the treatment options, drug eluting stents appear to provide the most benefit.


The following are one of the classifications for restenosis:[1]

The need for recurrent target lesion revascularization (TLR) increased with increasing ISR class, increasing from 19%, 35%, 50%, to 83% in classes I to IV, respectively (P <0.001)[1].


Epidemiology and Demographics

ISR is found in 5% to 10% of patients undergoing PCI.[9][10]




2021 ACA Guidline Recommendations

Class 1 Recommendation, Level of Evidence: A[2]
If another PCI is planned for a patient with clinical in-stent restenosis (ISR), drug eluting stent (DES) is recommended with goal of outcome improvement (if anatomic factors and dual antiplatelet therapy (DAPT) compliance are considered).
Class 2a Recommendation, Level of Evidence: C-EO [2]
If a patient with recurrent symptomatic diffuse in-stent restenosis (ISR) has a revascularization indication, planning CABG is preferred over repeat PCI to lower recurrent events.
Class 2b Recommendation, Level of Evidence: B-NR [2]
In a patient with recurrent in-stent restenosis (ISR), brachytherapy could be helpful to improve symptoms


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